One such combination is DHE combined with metoclopramide intravenously, with the latter treating the nausea induced by the former. Both of these medications were individually as effective as chlorpromazine in providing pain relief, although the combination did not appear to have additional pain-relieving effects. Magnesium can be an effective agent in migraine treatment, either alone or as adjuvant treatment, especially in those patients who have aura. It provided as much LDK378 molecular weight freedom from migraine pain (with and without aura) as did sumatriptan or ketorolac IV, although average pain relief was relatively low, only surpassing ketorolac IM and valproate. There is some support for using corticosteroids

to prevent headache recurrence, especially if the presenting migraine has lasted longer than 72 hours. The optimal regimen likely involves IV doses in the ED followed by oral dosing for several days post-discharge. It is recommended that all future studies be randomized and double blinded (including double dummy). For those rescue treatments for which there have been insufficient studies employing a placebo arm, it is recommended that Selleck XL765 this be done

to ascertain effectiveness more accurately. When drug combinations are compared, the same second agent should be used in both or all arms. An ideal design for studying drug combinations would have 4 arms: drug A/placebo B, drug B/ placebo A, drug A/ drug B, and placebo A/ placebo B. Recording of headache status should be done at 2 hours (in addition to any other outcome measures), even if this involves the patient reporting their status post-discharge, in order to determine the percent pain free at 2 hours. All studies should include 24-72 hour follow-up evaluations. In summary, the ideal acute migraine rescue therapy administered in the urgent care or ED setting

would provide complete headache relief, possess no side effects, and prevent early headache recurrence. Because no such therapy currently exists, treatment must be tailored to the needs of the individual patient. Triptans and DHE are most effective in injectable formulations and should be avoided in those at risk for vascular complications. DHE is particularly effective when given IV but Unoprostone can cause increased nausea. NSAIDs such as ketorolac have the advantage of being appropriate for patients with vascular risk factors, and they do not cause sedation. They can be combined with most other treatments for increased efficacy. Dopamine antagonists can be given alone or with other agents. As this review indicates, they are surprisingly effective for migraine, even late in the attack, and they are inexpensive. When used alone, prochlorperazine, droperidol, and metoclopramide were superior to placebo. Droperidol and prochlorperazine were superior or equal in efficacy to all other treatments, but they commonly cause side effects that are especially unpleasant for patients (notably dystonia and akathisia).